Case presentation

Transthoracic Echo. in the I.C.U and emergency department Case presentation & literature reviewCase presentation Two cases Dr. Saad SubahiConsultant cardiologist at ALRIBAT university hospital Case (1) 46 old male admitted electively to hospital on 12/05/2010 for lamincectomy

MRI showed disc prolapse at L4&5No significant P.H

Next morning (13/05/2010) he had inter laminar discetomy, done under G.A.Uneventful course 2nd post-operative day, at 10:30 a.m (Friday) he was seen by the neurosurgeon Patient was comfortable, apart from minimal backacheVitals were stableHe was advised to mobilize out of bed Immediately after mobilization patient developed sudden SOB; taken back to bed, noticed to be sweaty with cold extremities .

Soon, prior to any intervention, respiratory and subsequently, cardiac arrest ensued

Advanced cardiac life support was immediately implemented.After resumption of spontaneous circulation he was transferred to ICU

Before connecting him to M.V. he had second arrest; CPR (for 3 minutes) -----> Resumption of spontaneous circulationGiven 2 liters of N/S because of B.P of 75/45, followed by dopamine infusion, titrated up to 20mcg/kg/minHe was connected to M.V. at 11:0 a.mI attended the patient at 11.30 amVital signs : pulse 145/min; B.P : 88/52; oxygen sat 99% There was prominent jugular venous distention.

The lungs were clear on auscultation, with normal breath sounds

12-lead ECG showed sinus tachycardia, S 1Q 3T 3 pattern & RBBB Chest x-ray : normalCBC, Urea & electrolytes were normal

A presumptive diagnosis of massive pulmonary embolism was made .At 12:15 p.m seen by Dr. Saad & bed side ECHO doneDr SaadECHODaignosisDiscussed with the neurosurgeon and started on streptokinase 1.5 million units, over one hour .Events during streptokinase infusion .Hypotension & bradycardiaSevere biventricular dysfunction ------- adrenaline infusion Improvement in biventricular function, pulse rate & blood pressureD/C of adrenaline infusion Maintenance of normal B.PRecovery of RT ventricular function Diagnosis: Massive PE-induced cardiac arrest + right heart thrombi-in-transitAt 1:30 pm was hemodynamically stable .ECHO, next morning (15th) , at 8:15 am At 10:0 am :Improvement in BP & O2 saturation, & he was obeying commandsShifted to spontaneous mode : TV > 300ml, rate 25-28/min & oxygen saturation 100% on FIO2 0.40

Accordingly he was extubated and connected to oxygen by simple mask (50%) ABG 30 min post extubation :PH : 7.35PCO2 : 37 mmHgPO2 : 163 mmHgO2 sat : 99%HCO3 : 22 mmol/LBE : -3 mmol/L

Time from clinical suspicion to thrombolytic therapy : one hour Case (2)3133 years female presented to the emergency room with 2 hours history of sudden shortness of breath3/08/2011 at 10.0 am One week prior to presentation she had bilateral fracture of the tibial shaft (RTA), treated conservatively at home (long leg casting) . Was completely confined to bed .

On presentation to A&ETachypnic : 40/minPulse : 140/min.B/P : 70/35Confused & restlessNormal 1+11 heart soundsChest : normal auscultationECG : sinus tachycaria , inverted T- in V1-3ABG (NRM) : PH : 7.29 PCO2 : 31 mmHg PO2 : 66 mmHg HC03 : 16 mmol/l

Chest x-ray : normal

High clinical suspicion of massive PE .ECHO : done by Dr Saad, within 15 min from time of presentation .1 liter of N/S, followed by dopamine infusion

ECHO.Started immediately on IV streptokinase 1.5 million units over one hour .ARRESTED : CPR was carried and streptokinase infusion was continued during CPRShe was intubated and CPR continued for 12 min ------ > ROSC

Transferred to ICU on dopamine infusionConnected to the ventilatorImprovement of oxygenation, but continued to require inotropicsOn the same day she had 2nd arrest at 9:30 pm .CPR for five minutes ------> ROSCHospital courseAKI required peritoneal dialysisAcute peritonitis Recovered with a polyuric phase, during which she developed massive hematuria .On day 5 : massive upper GIT bleeding required blood transfusion.On day 7 : blocked ETT .

Day 11 on mechanical ventilation, she satisfied all extubation criteria .She was extubated and connected to oxygen by simple mask . After 29 days in ICU she was transferred to the ward, fully conscious and oriented with normal renal function; and discharged home 5 days later .

Time from clinical suspicion to thrombolytic therapy : 20 min.Transthoracic ECHO was done at the bedside in critically ill patientsPerformed by the clinician who has complete knowledge of the patients current clinical statusImmediately established the diagnosis and directed towards the appropriate intervention .Focused (Goal-directed) Transthoracic Echocardiography in the I.C.U and emergency department

POLICY STATEMENT Emergency Ultrasound Guidelines Approved October 2008

Focused Cardiac Ultrasound in the Emergent Setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians

J Am Soc Echocardiogr 2010;23:1225-30.

Bedside Applications of Ultrasound

Cleveland Clinic February 2013

IntroductionIt was unimaginable 100 years ago to be able to draw a picture from sound. Similarly it was written in The Times in 1834: The medical profession was unlikely ever to start using the stethoscope because its beneficial application requires much time and gives a good bit of trouble.Ultrasound, which is our future stethoscope, has passed through the same story, as the medical community was initially reluctant to use it for diagnosing life-threatening conditions by nonradiologists.

Early ultrasonography machines were bulky and their use was confined to imaging laboratories.

Compact and portable ultrasound machines that provide excellent image quality

Has resulted in profusion of bedside applications

The concept of an ultrasound stethoscope is becoming a reality.

Ultrasonography has been widely used in cardiology, radiology, obstetrics, and emergency medicine.

More recently, its use has become more widespread in pulmonary and critical care medicine.

Bedside Applications in Pulmonary and Critical Care MedicineUltrasonography conducted at the bedside by a clinician, known as point-of-care ultrasonography, dates back more than twenty years, but has come to prominence in the last 5-7 years and is spreading quickly.Has 2 primary uses in pulmonary and critical care medicine:Procedural guidance Rapid bedside diagnosis in critically ill patientsUltrasound-guided procedures Some of the common ultrasound-guided procedures performed in the critical care unit include Establishing vascular access and monitoring catheters

Pericardiocentesis

Thoracentesis and pleural catheter placement

Paracentesis

Lumbar punctures

Arthrocentesis

Regional anesthesia

Ultrasound guided crycothyrotomy and tracheostomy

Confirmation of transvenous pacing wire placement

Diagnostic applications of Point-of-care ultrasoundIn contrast, to formal ultrasound; is performed by the clinician who is currently caring for the patient and who has complete knowledge of the patients current clinical status. Interpretation of the ultrasound images and immediate clinical decisions are made by the clinician conducting the imaging study, thereby enabling rapid intervention and assessment.

The dynamic nature of the techniques and ability to repeat an examination rapidly, as needed without waiting on an imaging specialist to perform the examination and interpret it, allows the individual intensivist to monitor patient progress and effects of therapeutic interventions.Advantages point-of-care ultrasoundFastPerformed at the bedsideNon-invasiveImmediate resultsRepeatableNonexpensivewithout the risk of radiationPoint-of-care ultrasoundGoal-Directed EchocardiographyLung UltrasonographyGoal-Directed Abdominal Ultrasonography Goal-Directed Vascular UltrasonographyLung UltrasonographyInternational evidence-based recommendations for point-of-care lung ultrasound.

Intensive Care Med (2012) 38:577591Pleural effusion

Pneumothorax

Lung consolidation

Interstitial syndromePulmonary edema of various causesInterstitial pneumonia or pneumonitisDiffuse parenchymal lung disease (pulmonary fibrosis)

The four chest areas per side considered for complete eightzonelung ultrasound examination. These areas are used to evaluatefor the presence of interstitial syndrome.

Focused (goal-directed) echoSince its inception over 60 years ago, echocardiography has remained largely the province of the cardiologist, providing a tool to evaluate anatomical and physiological abnormalities of the heart.In recent years, the application of echocardiography has extended to the diagnosis and monitoring of the critically ill patients in the general intensive care unit --------------> Goal-directed Echo

Transthoracic Echo, performed at the patients bedside and interpreted by the treating intensivist to answer specific clinical questions.

The principal role for FOCUS is the time-sensitive assessment of the symptomatic patient.Clinical Indications for Focused Echo Hypotension/Shock Dyspnea/Shortness of Breath Chest painCardiac TraumaCardiac Arrest Goals of the Focused echo in the Emergent SettingAssessment of global cardiac systolic function and contractility Assessment of the right ventricular functionAssessment for the presence of pericardial effusion

Intravascular Volume assessment

Cardiac arrestVolume AssessmentChest pain Cardiac arrest Successful resuscitation requires potentially reversible causes to be diagnosed and reversed, and many of these can readily be diagnosed using echocardiography.Periresuscitation echocardiography provides the only realtime bedside diagnostic tool that can diagnose some of the potentially reversible causes of cardiac arrest and can be regarded as analogous to pulse oximetry or ECG monitoring. Focused echocardiography can be performed within the time frame allowed during the pulse check of the advanced life support (ALS) algorithm.

A sub-xiphoid probe position has been recommended.

The goal of the FOCUS in the setting of cardiac arrest is to improve the outcome of cardiopulmonary resuscitation by:

Determining a cardiac etiology of the cardiac arrest : TamponadeCoronary artery diseasePulmonary embolismhypovolemia Identifying organized cardiac contractility to help the clinician distinguish between: -Asystole -Pulseless electrical activity (PEA) and -Pseudo-pulseless electrical activity,

True PEA is defined as the clinical absence of ventricular contraction despite the presence of electrical activity. Whereas pseudo-PEA is defined as the presence of ventricular contractility visualized on cardiac ultrasound in a patient without palpable pulses.Therefore, making the diagnosis of pseudo-PEA can be of diagnostic and prognostic importance.If mechanical contractility without palpable pulse is identified (pseudo-PEA), the management can then focus on hypotension rather than asystolic type resuscitation pathways.Lastly Guiding life-saving procedures at the bedside such as pericardiocentesis, or evaluate the position of transvenous pacemaker placement.

Volume AssessmentIn the critically ill, a number of parameters have been found to indicate severe hypovolaemia.These include :

The presence of a small, hyperkinetic left ventricle (in the presence of a normal right ventricle) with end-systolic cavity obliteration.

A left ventricular end-diastolic area of less than 5.5 cm2/m2 body surface area. A small inferior vena cava (diameter